Tuesday, August 4, 2015

Rotator cuff surgery in the weight-bearing shoulder - a challenging situation

Arthroscopic rotator cuff repair in the weight-bearing shoulder.

These authors reviewed 46 'weight bearing' shoulders in wheelchair-bound patients having arthroscopic cuff repair with a mean follow-up of 46 months.

Of the shoulders, 87% had supraspinatus involvement, 70% had subscapularis involvement, and 57% had an anterosuperior lesion involving both the supraspinatus and subscapularis. 

The authors describe the use of an abduction splint for 6 weeks after surgery in cases of supraspinatus and infraspinatus involvement with increased tension on the repair. Patients were hospitalized for about 10 weeks in a center for paraplegic patients. The postoperative rehabilitation
protocol included use of an electronic wheelchair and strictly passive exercises under the supervision of a physical therapist during the first 6 weeks. After 6 weeks, limited indoor manual wheelchair use was allowed. Transfer training was started after 8 weeks invariably with the use of a transfer board until 4 months postoperatively.

33% of the repair attempts failed by ultrasound, 5 of these 17 patients had a clear traumatic event.

The patients showed improvements in the Constant-Murley score from 50 points  preoperatively to 80 points postoperatively and in the American Shoulder and Elbow Surgeons score from 56 points preoperatively to 92 points postoperatively, with a mean postoperative Subjective Shoulder Value of 84%.

Comment: Patients using wheelchairs are special. They are usually intensely dedicated to their personal independence.  They place extraordinary loads on their rotator cuffs: in ambulation, in transferring in and out of automobiles, chairs, bed and toilet, in work, in sports, in loading their chair in and out of a car and in the occasional fall.  The paraplegia often is accompanied by a high body mass index because of the difficulty in getting aerobic exercises. As shown in this study, the tear pattern in these patients has a high rate of subscapularis involvement (70%), suggesting that wheelchair users may place more load on this tendon than other patients. 

Paraplegic patients having cuff surgery require extraordinary care in their rehabilitation. The authors do not describe how the repair is protected from loading when the patient rises from the bed or chair or performs transfers during the first two months after surgery. In our experience the difficulty of caring for a repair under these circumstances is huge.  

In our practice, acute tears in wheelchair-bound patients receive consideration for acute repair after a thorough discussion of the complexities of the prolonged rehabilitation period. Chronic tears are generally managed with activity modification and device assists (lifts for getting the chair in a car, transfer boards, elevated toilet seats, overhead bars), help with body weight reduction if necessary, and fall prevention strategies. Surgery is not encouraged for most degenerative tears. 


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